AHCCCS Application Form DE-103: Medicare Savings Program Filing Guide

Form DE-103 is the official paper application for AHCCCS Medical Assistance and Medicare Savings Programs. For seniors who can't use the Health-e-Arizona Plus online portal — or whose portal session crashes mid-application — it's the most reliable way to get a filing date on record.

Where to Get Form DE-103

The form is available in English and Spanish from the AHCCCS website (azahcccs.gov) or the DES portal. Any DES Family Assistance Administration office will hand you a paper copy. It's titled "Application for AHCCCS Medical Assistance and Medicare Savings Programs" — the same form handles full Medicaid, SNAP, and Cash Assistance applications alongside MSPs.

What the Form Asks (and What Doesn't Matter for MSPs)

DE-103 covers multiple programs, so it asks questions that aren't relevant to a Medicare Savings Program application. The sections on assets — bank accounts, real estate, vehicles — appear because SNAP and full Medicaid have asset tests. Answer them honestly, but Arizona eliminated the asset test for QMB, SLMB, and QI. The eligibility engine skips those answers during MSP screening.

The sections that matter for MSPs:

• Personal information and Medicare status — Name, date of birth, Social Security number, and the Medicare Beneficiary Identifier (MBI) from the Medicare card
• Household composition — Single or married, living arrangements, whether the spouse also has Medicare
• Income — Gross Social Security, pensions, annuities, earnings. AHCCCS uses gross Social Security before any deductions
• Residency — Arizona driver's license number, state ID, or other proof of residence

Required Documents to Attach

Staple or paperclip these to the completed form:

• Copy of the Medicare card (or SSA Benefit Verification Letter confirming Part A/B entitlement)
• SSA COLA award letter or benefit verification letter showing gross monthly Social Security
• Pension or annuity statements if applicable
• Arizona residency proof — driver's license, utility bill, lease, or signed residency declaration
• Form DE-301 (Authorized Representative Designation) if an adult child is filing on behalf of a parent

Bank statements are not required. Pay stubs for the last 30 days are needed only if the applicant works.

Where and How to Submit

DE-103 can be filed three ways:

Mail — Send to the local DES Family Assistance office. Use certified mail with a return receipt to establish the filing date. That date determines retroactive coverage for SLMB and QI (up to 3 calendar months before the application month, if the applicant met eligibility criteria in those months; QI coverage cannot extend into a prior calendar year).

Fax — Each DES office has a fax number. Save the transmission confirmation report — it's your proof of filing date.

In person — Any DES FAA office accepts walk-in applications. Ask the worker to date-stamp your copy. Major offices in Maricopa County include the West Van Buren and Northern Ave locations. Pima County has offices on Commerce Park Loop and East Broadway. Rural counties have regional DES offices, and telephone appointments are available for remote areas.

Processing Timeline

AHCCCS must issue a decision within 45 calendar days from the date it receives the application. If 45 days pass without a response and you haven't been asked for additional documents, escalate to the local FAA office supervisor.

If AHCCCS requests additional verification (income, residency), respond promptly. Missing the verification deadline can result in denial for failure to cooperate — not for ineligibility.

For the full document preparation checklist and a tracking log that monitors every deadline from application through premium refund, the Arizona Medicare Savings Programs & Extra Help Guide covers the entire process.

See more Arizona guides →